Time to go back to the drawing board on mental health reform

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Disclosure statement

Jon Jureidini does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.

As the Commonwealth Government’s community consultation period for mental health reform comes to an end this week, health bureaucrats will begin finalising Australia’s Ten year roadmap for national mental health reform to “guide future action and investment”.

The roadmap correctly identifies two fundamental priorities in mental health reform: addressing the social determinants of health and injecting greater resources and energy into supporting those with serious mental illness.

But the 42-page document is based on some problematic assumptions about the causes and prevention of mental illness, and conflates illness with other forms of distress.

Road to a healthy society

The draft roadmap acknowledges that the future wellbeing of our society is contingent on significant investment in parenting, childcare, schooling and vocational opportunity. The problem is, the document classifies these ambitions as “longer-term actions”, which is too often a euphemism for merely aspirational.

It’s true that the benefits of such interventions will only become apparent in the long term, but that shouldn’t detract from the urgency of initiating action. Community-based programs that enhance parenting capacity (especially for younger mums and dads) and school-based schemes that build students’ emotional strength are just two examples of potential short- to medium-term actions.

Unfortunately, as many of us have come to expect from the government’s pronouncements on mental-health reform, the roadmap’s rhetoric is driven by sloppy thinking and populist notions.

The first sentence, for example, says “Mental health is fundamental to a person’s ability to lead a fulfilling and rewarding life”. But this ignores the context of the individual’s circumstances. There’s no doubt that we make judgements about our mental health based on how fulfilling and rewarding our life is.

Fifty years ago, many disenfranchised people were primarily identified by the fact they were unemployed and were regarded as miserable because of their lack of vocational opportunity. Now many of these same people are categorised as primarily depressed and unable to work because they are sick.

It’s also important that we don’t make overly optimistic assumptions about the benefits of the early interventions outlined in the roadmap and overly pessimistic assumptions about people’s capacity to recover without intervention.

The roadmap tells us that “two-thirds of those with mental illness will have experienced their first symptoms by the age of 21, and without support some may experience life long disadvantage”. But with or without support, some people will experience lifelong disadvantage. We can hope that intervention improves the chances of having a good outcome but there is little evidence to show it makes a dramatic difference.

Similarly, the roadmap overplays the link between depression and suicide. A critical reading of the literature shows that suicide is only partly about mental illness; intoxication with alcohol and other substances and the desire to escape pain at any cost are just as pertinent.

In each of these cases, the roadmap recommends providing immediate treatment for “sick” citizens rather than facilitating social reform.

The roadmap’s repeated use of the term “mental health problems and/or mental illness” highlights the inability to really define the boundaries of mental illness. We conflate socially determined dysfunction with bio-psychological disability and too readily apply mental illness labels as “unexplanations” of people’s predicaments.

Success in reforming the mental health system might be measured, in part, by our ability to be clearer about just what constitutes mental illness.

In the meantime, Australia’s ten-year reform plan needs to focus on the hard slog of setting up the building blocks that will allow Australians to lead happy, healthy lives.

Perhaps we require two separate roadmaps – the first to guide us in the management of serious mental illness and the second to lead us towards a fairer and healthier society. By seeking both destinations at once, there’s a risk that this roadmap will take us to neither.